A nurse is administering a prescribed intravenous medication to a client via an electronic infusion pump. Shortly after the medication is initiated, the client suddenly reports a severe headache, a tight feeling in the chest, and dizziness. The nurse observes intense facial flushing and notes a rapid, irregular pulse. Recognizing these manifestations as speed shock, in what chronological order should the nurse perform the following interventions? Arrange the actions from first to last.
- 1Stop the medication infusion immediately to halt further drug delivery.
- 2Disconnect the medication tubing and attach a new administration set primed with 0.9% sodium chloride.
- 3Obtain a complete set of vital signs and evaluate the client's cardiopulmonary status.
- 4Report the adverse reaction and current assessment findings to the healthcare provider.
- 5Document the event, interventions provided, and the client's physiological response in the health record.
Answer
The correct sequence for managing speed shock is: Stop the medication infusion -> Disconnect the tubing and attach a new administration set primed with saline -> Obtain a complete set of vital signs -> Report the findings to the healthcare provider -> Document the event in the health record.
The correct sequence prioritizes immediate client safety by stopping the infusion first. Crucially, the nurse must change the entire tubing setup before running normal saline to prevent flushing residual medication into the client. Assessment follows to gather objective data, which is then communicated to the provider. Documentation occurs last, only after the client has been stabilized.
Step-by-Step Solution
Key Concept
Management of Intravenous Speed Shock and Safe Parenteral Infusion Practices